Tailoring New York’s Health Home Model for Children

Eligibility Criteria and Network Requirements

New York State HH State Agency Partners March 3, 2014

Agenda• Introductions

• Overview of Today’s Discussion

• Federal/CMS Criteria Tailoring Health Homes to Serve Children

Kathy Moses – Senior Program MangerCenter for Health Care Strategies

• Review and Discussion of Comments Submitted by the Work GroupTailoring Health Home Eligibility Criteria to ChildrenNetwork Requirements

• Next Steps 2

CHCS: A non-profit health policy resource center dedicated to improving services for Americans receiving publicly financed care

o Priorities: (1) enhancing access to coverage and services; (2) advancing quality and delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity.

o Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement.

o CMS Health Home Information Resource Center: Via a contract with CMS, CHCS is the technical assistance provider to states interested in establishing Medicaid health homes

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Health Home Basics

• New state plan option created under ACA Section 2703 • Overall goal: improve integration across physical health,

behavioral health and long-term services and supports• Opportunity to pay for “difficult-to-reimburse” services

(e.g., care management, care coordination)• Flexibility for states to develop models that address an

array of policy goals • Significant state interest in evidence-based models to

improve outcomes and reduce costs• States receive an enhanced 90/10 federal match for the

first eight fiscal quarters of the health home benefit

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Federal Legislation

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Federal Authorization: Who is Eligible to Receive Services?

2 or more chronic

conditions

1 condition & risk of second

Serious Mental Illness

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1 Chronic Condition and “At-Risk” for Another

• At-risk criteria must be evidence-based; for example:Predictive risk scoreDocumented family history of a verified heritable condition Diagnosed medical condition with an established co-morbidity

to a chronic conditionVerified environmental exposure to an agent or condition

known to be causative of a chronic conditionShould show strong evidence in the medical literature that

having one of these conditions is strongly associated with high risk of developing another chronic condition (SUD, tobacco use, etc)

• Broad flexibility given to states to identify and define their own at-risk criteria; opportunity to define these criteria to focus in on priority populations

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Key Guidance for Developing Health Homes for Children

• States cannot target by age, thus cannot build a Health Home for only children or only adults;Condition-based eligibility criteria apply to all potential

eligibles and cannot be selectively applied by age group

• States may tailor a Health Home approach to meet the specific needs of adults and children by:Strategically identifying conditions and at-risk criteria for the

eligible population;Developing specific provider standards to meet the needs of

eligible population; and Defining Health Home core services with some detail.

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Targeting Health Home Populations

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State Health Home Activity

10*Some states may be in the planning phase.

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Approved Health Home Models

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Models Tailored for Children• Rhode Island

Focuses on children with special health care needsProvider qualifications defined around skill set of CEDARR

Family Centers

• Oklahoma (in development)Leverages existing Care Management Entities for children with

SEDIncludes family and youth/peer support on care team

• New Jersey (in development)Builds upon existing statewide Children’s System of CareAdds RN to care coordinator team, greater emphasis on

primary care integration

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Visit CHCS.org to…

• Download practical resources to improve the quality and cost-effectiveness of Medicaid services

• Subscribe to CHCS e-mail updates to learn about new programs and resources

• Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries

• Health Home Information Resource Center website: • http://www.medicaid.gov/State-Resource-Center/

Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html 13

Work Group Comments on Tailoring Health Home

Eligibility Criteria for Children

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Overview of Work Group’s Comments on HH Eligibility• Generally, all Work Group comments “rejected” the notion that eligibility criteria

be solely based on chronic conditions. Comments were a mix of: Condition-based criteria Non-condition based criteria (including “Situational”, “At Risk” and “Level of

Care” criteria)o Can some of the non-condition based criteria be “converted” to condition-

based criteria?

• Work Group identified the following children’s populations to be targeted to served by Health Homes:

Medically Fragile Children Foster Care Waiver Programs Juvenile Justice Children with complex conditions

• As we review comments consider a potential approach for developing eligibility criteria the State can informally discuss with CMS that identifies (as much as possible) chronic conditions and uses “at risk” notion to try to capture some of the non-conditioned based criteria

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Work Group Comments that Identified or IncludedChronic Conditions to Determine Eligibility

• Work Group consistently agreed SED should be part of eligibility criteria Discussion: Should trauma be considered? As a separate

condition? As an amendment to the SED Definition?

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SED (Federal Waiver Definition): means a child or adolescent has a designated mental illness diagnosis according to the most current DSM of Mental Disorders AND has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis. The functional limitations must be moderate in at least 2 of he following areas or severe in at least on of the following areas:

(i) ability to care for self (e.g. personal hygiene; obtaining and eating food; dressing; avoiding injuries); or(ii) family life (e.g. capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or(iii) social relationships (e.g. establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or(iv) self-direction/self-control (e.g. ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability); or(v) ability to learn (e.g. school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

Condition-like Criteria

Conditions that May be Used to Represent Condition-Based Criteria / Comments

Include notion of HIV “Exposed”

Clarify/Ensure HIV current criteria includes notion of “exposed at birth”

Special Conditions as Defined by Federal government?

Need clarification of comment

Children deemed eligible for Medicaid due to diagnosis

Need clarification of comment

Children with Complex Needs

Are there conditions behind children with complex needs?

Early Intervention Criteria (for children under age 3)

Includes the following types of conditions:SyndromesNeuromuscular/musculoskeletal disordersCentral Nervous System AbnormalitiesHearing Vision and Communication DisordersPsychiatric/Emotional/Behavioral Disorders (

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Work Group Comments that Identified Condition-Like Eligibility Criteria

Non Condition-Based (“Level of Care”) Eligibility Criteria Proposed by Work Group

• Children that:Require care in residential treatment facility (RTF) (Children

w/SED)Are deemed eligible for placement in RTF (Children w/SED)Require Psychiatric hospital level of care, Require ICF level of care, Would otherwise be placed in a facility if did not have to

supports to live in community-based settingWithin the last 60 days had, or is projected to have within the

next 60 days, an inpatient admission for specialty care at a NICU, PICU or specialty children's hospital

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Non Condition-Based (“Level of Care”) Eligibility Criteria Proposed by Work Group

• Children that: Have had or are projected to have numerous ER visits or one

or more inpatient admissions related to the underlying MFC medical condition, where the cause of the visits or admissions is related to serious medical deterioration which goes beyond lack of appropriate primary care.

Children with certain levels of functionality, or limitationso Consider use of Assessment tool to determine level or

limitation (ACE or CANS, GAF, DLA-20)Repeatedly use crisis response services and/or emergency

room services

• Other comments: Allow children to remain in HH one year after discharge from RTF and exiting Foster Care 19

Non Condition-Based (“Situational”) Eligibility Criteria Proposed by Work Group

• Children in Foster Care • Children in Juvenile Justice System • Unstable family environment,

family/parenting risk and strengths, psychiatric or SUD history and/or diagnosis. If parent (birth) guardian or guardian is

enrolled in or qualifies for HH child is automatically eligible oDiscussion: Consider impact on overall

enrollment and Health Home appropriateness criteria for child

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Non Condition-Based (“At Risk”) Eligibility Criteria

Proposed by Work Group • At risk for 2 or more adverse childhood experiences (ACE)

or exposure to traumatic eventsDefinition of ACE and trauma

• High need, high risk as measure by assessment tool (e.g., CANS)

• At risk or repeated use of out-of-home placement, as defined by a child who has:Experienced more than 30 days of out-of-home placement

prior to age 12 (cumulative placements at RTC, RTF, state inpatient psychiatric hospitals, ATC, Community Residence, OCFS JJ facilities, secure and non-secure detention, OCFS licensed Group Homes, Foster family care or out-of-home residential school placements that were determined through an IEP)

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Definitions of HH Eligibility Proposed by Work Group

Medically Fragile Children (Definition from February 2013 MFC Report): An individual who is under 21 years of age and has a chronic debilitating condition or conditions*, who may or may not be hospitalized or institutionalized, and is: •technologically-dependent for life or health-sustaining functions, and/or•requires a complex medication regimen or medical interventions to maintain or to improve their health status, and/or•in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at risk.

 * Example conditions include: Bronchopulmonary dysplasia, cerebral palsy, congenital heart disease, microcephaly, and muscular dystrophy (see Attachment C of MFC Report)

Other States (information that might be helpful):o Oregon MFC – MFC unit Clinical Criteriao Michigan – Assessment for MFC Children in Foster Care

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Definitions for HH Eligibility Proposed by Work Group

• Any child meeting the Children and Youth with Special Health Care Needs (CYSHCN) definition as defined by the Maternal and Child Health Bureau (MCHB) of Federal Health and Human Resources Administration (HRSA) would be eligible for HH “…those who have or are at increased risk for a chronic physical,

developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Definition considers:o Situational criteria is consideredo Trauma, family disruption, child abuse and child neglect is consideredo Adverse Childhood Events (ACEs) scores are considered

• Discussion: Would definition capture all Foster Care children? Waiver Children?

Medically Fragile Children? Can the conditions be defined? Are they different than the chronic

conditions included in current HH eligibility definition? What is the benchmark for what is required by children generally? How is “at risk” defined

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Work Group Comments on Appropriateness Criteria for Health Homes

• Health Home program intended to target high cost / high utilizers of Medicaid services with chronic conditions that require care management to navigate an array of providers and services to improve overall outcomes

• “At Risk” types of eligibility criteria suggested by Work Group might be helpful in developing “appropriateness criteria”

• Add trauma to list of examples of “at risk for adverse event” to appropriateness criteria

• Add enrollment of of family member (birth, foster, adoptive) in Health HomeDiscussion: should also consider parent’s level of acuity and

needs of child24

Developing Chronic Condition Based Criteria to Expand HH Eligibility Criteria to Include

Children• Challenge: Develop chronic condition-based criteria around

children’s populations:Children in current waiver programs Foster Care childrenMedically Fragile ChildrenInvolvement with Juvenile Justice system

• What are the primary chronic health conditions of these children? Do most of these conditions put the child “at risk” for second or multiple other chronic conditions?Keep in mind expanded criteria will be applicable to adults Keep in mind current chronic condition criteria apply to

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Developing Chronic Condition Based Criteria to Expand HH Eligibility Criteria to Include

Children• New Chronic Conditions

Can be single condition for eligibility Can be added to eligible list of chronic conditions to be part of 2 chronic

condition criteria Can be one chronic condition plus at risk for another

• Single Chronic Condition: SED (complement to current SMI single chronic condition for HH

eligibility) HIV (current single condition criteria, but clarify would include HIV

exposed children) Others (MFC?)

• Two chronic conditions – MFC?• Chronic Condition +At Risk• At Risk: Discuss Foster Care, Juvenile Justice, Determined by

Assessment (CANS?) Example: Trauma + At Risk – in Foster Care

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Work Group Comments on Tailoring Health Home

Network Requirements to Serve Children

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Tailoring Health Home Network for Children

(January 27, 2014 Discussion)• HH Applicant must Demonstrate Capacity and Ability of Network to:

Meet child specific Health Home qualifications and standards (developed by state team with input from Children’s Health Home Work Group and Health Home Managed Care Work Group) and to abide by the principles for serving children and families

Meet the needs of complex populations (e.g., children with chronic conditions, those with SED/SUD, children in the Foster Care and Juvenile Justice systems)

Partner with school districts and the education system

Requirement to partner with and use Foster Care agencies for care management when a child enters Foster Care

• HH care managers are not limited to providers in the HH network and can link members to services outside the HH network 28

Tailoring Health Home Network for Children

(January 27, 2014 Discussion)• Generally , the Work Group comments were consistent with the expanded network requirements discussed at January 27, 2104 meetingPersons and entities that have experience in providing care

management for children (i.e., Foster Care agencies, B2H, TCM for Children, HCBS)

Pediatric Health Care Providers and Specialty Providers– Primary Care, Developmental Health, Behavioral Health, Substance Use Disorder Services, HIV/AIDS, Dentists

Volunteer Foster Care Agencies and Foster Care System o Foster Care Agencies provide care management for children in Foster

CareYouth and Family Peer SupportsEarly Intervention (EI)Education – Preschool Special Education and Committee on

Special Education Juvenile JusticeWaiver Services [1915(c)]Other ??

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Work Group Comments on Who May Apply to Serve Children and the Geographic Areas of

Service

• Current Health Homes may apply to expand their Network to serve children

• Other entities may apply to serve as a children’s Health Home (i.e., only serve children)

• Health Homes serving children would serve regions (i.e., areas of service that are different than the county-based regions currently serving adults)

• Offer at least two Health Homes in each region and no more than 4 allowed in NYC metro regionGeneral Comment: Ultimately, actual regions will likely

depend upon interest of existing HHs in expanding networks and HH partnerships that may form to primarily serve children 30

Work Group Comments on Types of Providers Identified to be Included in Children’s Network

• Ensure that Health Home has a network of providers (behavioral and health providers, primary, and specialty and sub-specialty providers) that has the set of skills, expertise, experience and cultural competence to serve children, including:Providers with Children and Adolescent Capacity, including:

o General and Children’s Hospitalso Private psychiatric hospitals o Alcohol Treatment Centers o Mobile Crisis Teamso Assertive Community Treatment Teams (ACT Teams)o School-based Health Centers and School-based Mental Health

Clinicso OMH licensed Children’s Community Residenceso OMH Home and Community Based Waiver Services Providerso OMH licensed Children’s Day Treatment Providers 31

Work Group Comments on Types of Providers Identified to be Included in Children’s Network

Full array of Pediatric specialty care practices, including those with OMH training for treating youth with mild, moderate behavioral health needs and pediatric respiratory vendors

Residential Treatment Facilities Residential Treatment Centers with specialty behavioral

health units, Intensive Treatment Units or alcohol and substance use units

Crisis/respite providersArticle 31 clinics with specialty provider designationPediatric dental and pediatric orthodontic providers

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Work Group Comments on Types of Providers Identified to be Included in Children’s Network

Other providers of:oYouth/peer support groupso Support groups for Foster parents/education for

foster care parentso Infant and child stimulation programsoEarly childhood educationoNutritional support through special

Supplemental Nutrition Program for women, Infants, and Children (WIC)

oTraining for caseworkers 33

Other Types of Providers Identified by Work Group that are now Included in Existing HH

Networks • Health and Medical• Behavioral Health • Community and social support services • Residential Treatment Centers• Residential Treatment Facilities• Residential Treatment Centers with specialty behavioral health

units, Intensive Treatment Units or alcohol and substance use units

• Crisis/respite providers• Article 31 and Article 32 clinics with specialty provider

designation• Diagnostic Treatment Centers• Dental practices (some may serve children)• Cultural competency (SPA requirement)• Residential needs/housing 34

Work Group Comments Include Existing Child Care Managers in Health Home Networks

• Child Welfare agencies must be provided the opportunity to serve as Downstream Care Management entities for the children and youth in Foster Care who are placed with them

• MH providers employed by Foster Care Agencies• OMH Children’s TCM Providers • B2H and OMH SED (1915(c))waiver service providers • Do not mandate B2H, OMH, HCBS or CAH Waivers transition to

HHs until behavioral health transition to MC is implemented Children/Legacy clients of those programs may transition at later

dateTo facilitate readiness, waiver care managers need to become part

of network “at launch” and begin to serve Children that qualify for HH Services 35

Work Group Proposal to Issue Request for Information

• Work Group Proposal: DOH should issue a Request for Information prior to the Request for Applications to provide an opportunity for stakeholders to give input on the specific requirements for Health Homes serving Children

• Alternative for Discussion: DOH issues a draft Request for Application for CommentStreamlines administrative processEncourages discussion and collaboration among children’s

providers, Health Homes, and Plans

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List of Providers Serving Children

• Working with State Agency Partners to develop list

• Consider including list in draft Application

• Will help encourage collaborative discussions between children’s providers and existing Health Homes (these discussions should be going on now)

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Other Work Group Comments

• Some members of the Work Group also submitted comments on the following topics:Methods or approaches to care management (care

coordination standards and training)Process for HH assignments and referrals ConsentPayment Rules Quality

• These Topics will be discussed at Future Meeting(s)38

Next Steps / Feedback and Comments

• Receive additional comments from Work Group and develop proposed eligibility criteria for Work Group Review State has informal discussions with CMS on proposed criteria

• Draft Children’s Health Home Application Circulate draft Application for review to:

o Work Group o HH/MCO Work Group

Post draft Application for public review and comment

• Other Topics to Be Discussed, Comments may be Submitted Methods or approaches to care management (care coordination

standards and training) Process for HH assignments and referrals Incorporate Children’s Consent Procedures and Forms in Health Home

Model Discuss Transitional Provisions – Policy and Payment Rules Tailor Quality Measures for Children

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Reference Slides

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Existing Eligibility Criteria for Health Homes

Will be Modified for Children

• Person Must be enrolled in Medicaid and have: Two chronic conditions or One single qualifying

condition ofo HIV/AIDS oro Serious Mental Illness

(SMI)

• Chronic Conditions include (but are not limited to) Alcohol and Substance Abuse Mental Health Condition Cardiovascular Disease (e.g.,

Hypertension) Metabolic Disease (e.g.,

Diabetes) Respiratory Disease (e.g.,

Asthma) Obesity BMI >25

• Persons meeting criteria must be appropriate for HH Care Management At risk for adverse event, e.g.,

death, disability, inpatient or nursing home admission

Inadequate social/family/housing support

Inadequate connectivity with healthcare system

Non-adherence to treatments or difficulty managing medications

Recent release from incarceration or psychiatric hospitalization

Deficits in activities of daily living Learning or cognition issues

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Health Home Chronic ConditionsMajor Category: Alcohol and Substance Abuse

Alcohol and Liver Disease Chronic Alcohol Abuse Cocaine Abuse Drug Abuse – Cannabis/NOS/NEC Substance Abuse Opioid Abuse Other Significant Drug Abuse

Major Category: Mental Health Bi-Polar Disorder Conduct, Impulse Control, and Other Disruptive Behavior Disorders Dementing Disease Depressive and Other Psychoses Eating Disorder Major Personality Disorders Psychiatric Disease (Except Schizophrenia) Schizophrenia

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Health Home Chronic Conditions

Major Category: Cardiovascular DiseaseAdvanced Coronary Artery DiseaseCerebrovascular DiseaseCongestive Heart FailureHypertensionPeripheral Vascular Disease

Major Category: Metabolic DiseaseChronic Renal FailureDiabetes

Major Category: Respiratory DiseaseAsthmaChronic Obstructive Pulmonary Disease

Major Category: Other 43

Tailoring New York’s Health Home Model for ChildrenChildren’s Health Home Work Group

• Children’s Health Home Work Group Work Group will develop recommendations (e.g., network

requirements, eligibility, transitional payment and policy provisions, consent) to present to Health Home/Managed Care Work Group

o Members of MRT Children’s Behavioral Health Work Group

o Members of Medically Fragile Children Work Group

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Existing and Modified Eligibility Options Target Conditions (2011 Medicaid Data)

Number of Children

Children that Meet Existing HH Eligibility Criteria

Foster Care (With SMI*, HIV or 2 or more Chronic Conditions) 6,152

Medically Fragile Children (With SMI*, HIV or 2 or more Chronic Conditions) 3,558

Foster Care and Medically Fragile Children (With SMI*, HIV or 2 or more Chronic Conditions)

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All Other Children (With SMI*, HIV or 2 or more Chronic Conditions) 80,112

Total 89,886

Potential Eligibility Modifications

Foster Care not Eligible under Existing Criteria 27,070

Medically Fragile Children not Eligible under Existing Criteria 8,393

Expanded MH Definition SED-Like 63,344

Foster Care and Medically Fragile Children not Eligible under Existing Criteria 131

Foster Care and SED –Like not Eligible under Existing Criteria 3,459

SED Like and Medically Fragile Children not Eligible under Existing Criteria 173

Foster Care, SED and Medically Fragile Children not Eligible under Existing Criteria 4

ADHD 42,243

Total 144,817

Total Children that Meet Current and Potential Eligibility Modifications 234,703

*SMI: Schizophrenia, Bi-Polar Disorder, Depressive Psychosis** Expanded MH Definition – Single condition of eating disorder; conduct, impulse control, other disruptive behaviors, major personality disorders, chronic mental health diagnoses, depression, chronic stress and anxiety, post traumatic stress disorder)Total Foster Care Children: 36,830Total Medically Fragile Children: 12, 868

Principles for Serving Children in Health Homes and Managed Care

• Ensure managed care and care coordination networks provide comprehensive, integrated physical and behavioral health care that recognizes the unique needs of children and their families

• Provide care coordination and planning that is family-and-youth driven, supports a system of care that builds upon the strengths of the child and family

• Ensure managed care staff and systems care coordinators are trained in working with families and children with unique, complex health needs

• Ensure continuity of care and comprehensive transitional care from service to service (education, foster care, juvenile justice, child to adult)

• Incorporate a child/family specific assent/consent process that recognizes the legal right of a child to seek specific care without parental/guardian consent

• Track clinical and functional outcomes using standardized pediatric tools that are validated for the screening and assessing of children

• Adopt child-specific and nationally recognized measures to monitor quality and outcomes

• Ensure smooth transition from current care management models to Health Home, including transition plan for care management payments

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New York State Health Home Model for Children

Health HomeAdministrative Services, Network Management, HIT Support/Data Exchange

HH Care CoordinationComprehensive Care ManagementCare Coordination and Health PromotionComprehensive Transitional CareIndividual and Family Support Referral to Community and Social Support ServicesUse of HIT to Link Services

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Managed Care Organizations (MCOs)

Note: While leveraging existing Health Homes to serve children is the preferred option, the State may consider authorizing Health Home Models that exclusively serve children.

**Foster Care Agencies Provide Care Management for Children in Foster Care

Net

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DOHAI/COBRA

DOHAI/COBRA

Waivers (OMH SED,

CAH & B2H)

Waivers (OMH SED,

CAH & B2H)

OMH TCM

(SCM & ICM)

OMH TCM

(SCM & ICM)

Pediatric Health Care

Providers

Pediatric Health Care

Providers

OASAS/ MATS

OASAS/ MATS

Care Managers

Serving Children

Care Managers

Serving Children

Access to Needed Primary, Community and Specialty Services(Coordinated with MCO)

Pediatric & Developmental Health, Behavioral Health, Substance Use Disorder Services, HIV/AIDS, Housing, Education/CSE, Juvenile Justice, Early and Periodic Screening Diagnosis and Treatment (EPSDT) Services, Early Intervention (EI),

and HCBS /Waiver Services (1915c/i)

OCFS Foster Care

Agencies and Foster Care

System**

OCFS Foster Care

Agencies and Foster Care

System**

Care Managers

Serving Adults

Care Managers

Serving Adults

(Will support transitional care)

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10.16.13